Month: April 2017

First there were the “barefoot doctors” of the Mao period. They were minimally trained cadres who brought basic health practices to largely illiterate rural masses. Then, as the country opened itself to a State controlled market economy and tens of millions now literate people headed for jobs in the cities, health care was set loose to fend for itself—market style. Hospitals and doctors, with minimal support from the State figured out how to stay open and make a living by charging patients directly, both in the open through highly profitable pharmaceutical markups and under the table payments/gifts to doctors. There were many unintended consequences from this arrangement.
Now, in a third reform announced in 2013, the country has decided to rely on a health insurance mechanism to address the distortions created by reliance on the market. In just a few years, almost everyone in China has gotten at least some form of health insurance protection though one of three schemes. The goals of the current reform include shifting the location of care from overreliance on big tertiary care hospitals to a community based primary care system; improving the quality of the health workforce; reframing delivery into patient centered care, reducing out of pocket expenses through expanded insurance coverage, adopting “health in all policies” to improve population health and strengthening the medical device and pharmaceutical industries.
One example helps make several of the key points about the current health reform, a large community health center in Beijing, pictured above. Western and traditional Chinese medicine are practiced side by side here, which is rare. The center does about 600 outpatient visits a day and has 60 long term “rehabilitation” beds that are mostly end of life care for severely ill patients. This community health center, like many others in China, serves an older population. They use the Center to get their chronic disease medications more conveniently and at lower cost than going to the tertiary care hospital. They also make heavy use of the traditional Chinese medicine doctors and therapies. However, when many of these older residents are ill, they go directly to the big hospital. Unlike community health centers in virtually all the other countries I have visited there are very modest services for younger people and very little maternity and infant care. Routine prenatal and infant care, I was told, is at the big hospitals.
In China, a very high percent of the people regularly bypass the community health centers and smaller hospitals to go directly to the tertiary care hospital to get their care, even though that often means long waits for access, higher out of pocket costs and very brief physician encounters. Changing the pattern is a major objective of the current reform. All the policy makers I met talked about remaking community health centers into models of primary care and population health. Some of the academics and most of the doctors I have met so far are quite skeptical that the hospitals and patients will change their behavior.
Two days before I visited the Center, a major pricing reform was announced for all Beijing health providers. It is a major pilot program for the reforms. Signs describing the new prices were posted all over the Center. Hospitals and health centers in Beijing were ordered to stop marking up the price of medications. A new fee schedule was put in place under which patients will pay lower prices for medicine and most tests but higher prices for physician visits. There are two main reasons for the change. During the free market reform period when public money for hospitals and doctors was limited they financed themselves, in part, by the profits they made marking up medicines and tests. The incentive, of course, is to prescribe more and higher priced medicines and tests; and they did. By ending markups the government hopes to achieve more rational use of medicines. (40% of National Health expenditures are for medicine now.) The higher physician fees have two goals: helping make up for the losses the hospitals will take on medications and increasing respect for physicians as skilled professionals by having patients pay them more. (The most senior policy advisor I met said that the change won’t affect patients directly because insurance coverage for doctors’ fees will be “aligned” with the new prices. No one else said that has happened yet.)
According to most of the experts I have met and the doctors I interviewed at the Community Health Center, doctors, especially at the community health centers and district hospitals are held in low respect. Sometimes patients are disappointed that they don’t get the “cure” they paid for and blame the doctor for treatment failure. Sometimes they see the doctors and centers as just grabbing as much money from them as they can. Finally, patients know the doctors at the lower levels are not as well trained as the specialists at the tertiary care hospital. As one of the students at my presentation said: Every time I go to the Community Health Center I get referred to the specialist, so now I just go directly to the tertiary hospital. Why raising fees, without changing other aspects of the patient/doctor relationship will address issues of respect is still a mystery to me.

A note on Beijing.
Just because our hotel was tucked between the AstonMartin and Ferrari/Maserati dealers is no reason to think that Beijing is in an economic boom in which at least some people are getting very rich. We saw no significant signs of poverty or anything that resembled a “slum” in travels throughout the city. But many of the people we talked with spoke of rising income inequality in Beijing. Central Beijing looks a lot like Mid-town Manhattan, except the main streets here are wider. EVERY western retail fashion brand is present on a huge scale, especially the luxury lines. The monuments of ancient China like the Forbidden City and the spectacular National Museum amply demonstrate China’s 5000 year old culture. There are remnants of the old structure of the city called hutongs that are one and two story buildings with small courtyards where some semblance of another time can be seen. However, the dominant image is a huge western city of new high rise offices and apartments with the streets filled by young sophisticates in the latest hip styles. We saw very few children.
All street and building signs are in Mandarin and English. The younger a person is, the more likely she is to speak some English. The sidewalks and streets are spotless because there are uniformed public works people constantly sweeping and picking up paper. However, the air pollution is so thick it hurts the eyes, even on an otherwise beautiful Spring day.
The picture at the top of this post was taken from our hotel room. It makes several of the points I mentioned. In the near foreground is a small hutong. Then there are many high rises, obscured by smog. About 20 miles behind the high rises there are steep mountains that surround most of Beijing. We saw them through the smog only once.
Tianaman Square is a weird place. It is vast, surrounded on most sides by monumental government buildings and Mao’s tomb (currently closed for repairs). However, access to this great open space is completely controlled. They are taking no chance that the place will ever again be used for a gathering/protest that is not approved by the government. The space is completely gated and can be closed down in minutes. Everyone entering the square must go through a security checkpoint. Bags go through an xray machine and people go through a metal detector and physical pat down. On a recent weekday afternoon there was a heavy—though seemingly normal—police presence.
I am writing this on a train to Xi’an that is going 160 miles an hour and is every bit as comfortable and smooth as American trains are not. It makes the Acela look like an outdated trolley. We are passing through very intensively planted farmlands. Every few miles there is a new city rising out of the farmlands. Each new development has broad paved streets leading through dozens of 20 story apartments under construction or recently completed. The train just stopped in a city where we can see hundreds—really—of high rise buildings under construction. Some seem stalled in construction. Others are finished but it is not clear how full they are. We saw some sights like this just outside of Delhi and some other Indian cities but the infrastructure and building scale are vastly larger here. Even more breathtaking, however, is the smog. It is difficult to describe how thick it is. Even on this ultramodern train with great air conditioning my eyes hurt and it is hard to breathe. The Chinese government and people know how bad the problem is. Addressing air pollution is an explicit part of the new national health plan. The untrammeled development of the past 20 years is taking a toll that will be costly and slow to fix.

Sometimes seeing an entirely new situation clarifies something you have been looking at for years. That is what is happening to me as I got a glance of South Africa and India. All these countries share conditions that make implementing universal health coverage very challenging. (Brazil has these same factors so may face the same problems.)
• They are all federal systems in which individual States/provinces have real political power and significant control over health care delivery.
• They all have parallel public systems for the poor and better funded, private systems delivering care to people who can use private insurance or pay out of pocket.
• They have relatively unequal distributions of wealth.
• People and groups with political influence have easy access to the private delivery system and lack confidence in the public delivery system, especially at the primary care and routine hospital levels.
• People and groups using the private sector have the political clout to prevent efforts to redistribute resources to serve poor or other ethnic groups.

Obamacare will stay in place in the US, at least for a while but I think these factors may limit the country from reaching its goal of universal health coverage and may explain why some of the opposition has been so intense

India and South Africa recently announced major health reforms they hope will lead to universal health coverage over the next few years. Both intend to use an insurance mechanism, controlled at the national level to leverage significant changes in their primary care and regional hospital systems, especially around access, breadth of service and quality. The national governments have limited control over the delivery systems now. They hope the purchasing power they get by controlling insurance payments to the providers will give them more control. Obamacare includes major provisions that try to leverage change in the delivery system both directly and indirectly through its insurance reforms. Obamacare certainly tried to force big changes in State Medicaid programs until the Supremes said no. India and South Africa (and China as well) are trying to layer an insurance system on top of existing publicly owned and budgeted provider organizations. Neither country has yet developed an implementation plan to achieve the systems reform goal and neither has gone far enough down to path to know what kind or form of opposition from local forces will emerge. While insurance reforms have certainly affected provider behavior in the US, it is not clear—to me at least—that they have been particularly effective in improving quality or containing cost. In recent years employer based insurance has actually limited choice and braod access and shifted cost to employees. Private insurance has had very little impact on price or quality around the country.. The public insurance programs like Medicare and Medicaid have had marginally more impact on changing behavior. It is a constant cat and mouse game but the providers have beaten the insurers repeatedly. I wonder what will happen in other countries that rely on insurance mechanisms to change their delivery systems.

Many countries, including the US, are struggling with the issue of how to make better use of lesser trained community health workers to improve effective access to care for poor and socially isolated individuals. India has a program in villages and poor urban areas called the ASHA program. I got to visit an ASHA and one of her clients on a recent visit to a rural health center near Nagpur. I have a wonderful picture but the computer gods are not letting me copy it.

The program is tantalizingly simple. A woman is recruited (the selection process and criteria differ by location) in each village and urban neighborhood. For example there were 17 associated with the rural center I visited and about 40 linked to an urban maternity hospital I visited in Kochi. They get days to weeks of training on very basic issues of pre-natal, maternal and infant care, including how to do a basic pregnancy screen and register pregnant women with the health center. Their major goal is to get women registered for pre-natal care very early in pregnancy and to agree to deliver in a health center or hospital. ASHAs often accompany the women to visits and to the hospital for support. ASHA’s are paid for productivity, not time. They get paid for registering women and for getting them to deliver at a health center or hospital. They can also be paid to conduct specific health outreach or education campaigns that are part of a government initiative. Virtually all ASHA’s are part time, about two hours a day. Some get further training that enables them to take on more health tasks in the village or at the health center.

Birth outcomes have been improving in India and a higher percentage of deliveries are occurring in health centers and hospitals. ASHA’s get some of the credit for this trend. One of the advantages of early and more frequent pre-natal visits is classifying a pregnancy as low or high risk. Women who are high risk are urged to deliver at the higher level hospital. Many health centers now have basic ambulances to transport the women—and those accompanying her—to the hospital when she is due.

Since the incentives paid to ASHAs are very modest, it is fair to ask if money is the only motivating factor. Some observers think it is not about money. Rather, they argue that the ASHA program has been an empowerment program for poor women in villages and urban areas. The ASHA has status in the village. The pregnant women gain both new information about how to safely have a baby and how to seek what they need. An increasing number of women, for example, are demanding to be transferred to the larger hospital for their delivery. The ASHA also plays a major role in breaking the social isolation of rural women by accompanying them to the city hospital, where many would have been afraid to go on their own.

As India moves to implement its new national health policy the prospect of expanding the training and roles of ASHA’s in both individual and village population health is being discussed.

It is well worth reporting that the ASHA and young pregnant woman I visited are participating in a double blind clinical trial. Yes, a full blown high quality clinical trial in a village without electricity or plumbing. They are part of large multi-site study to determine the effect of low dose aspirin taken daily during mid pregnancy will lead to fewer pre term births, low weight babies and lower rates of eclampsia and pre-eclampsia and prenatal mortality. The site leader for the research is Archana Patel and the team at the Lata Medical Research Institute in Nagpur. They are longstanding BUSPH partners with Pat Hibberd and were wonderful hosts for my visit.

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